Thyroid Cancer: Assessment and Management in Secondary Care

Overview

This specialist Guidelines summary covers the diagnosis and management of thyroid cancer in people aged 16 and over. It aims to reduce variation in practice and increase the quality of care and survival for people with thyroid cancer.

This summary is for use by oncology teams. For further information, please refer to the full guideline.

Information and Support

Information for People with Suspected Thyroid Cancer

• When providing information, follow the recommendations on Enabling patients to actively participate in their care in the NICE guideline on patient experience in adult NHS services and Putting shared decision making into practice in the NICE guideline on shared decision making
• Explain to people with suspected thyroid cancer:
  • that not all lumps, nodules or swellings in the thyroid are cancer
  • what the diagnostic pathway involves and what tests they may need
• Advise people where to find reliable high-quality information and support after consultations, from sources such as national and local support groups, networks and information services.

Information for People Having Surgery

• Offer people with suspected or confirmed thyroid cancer, and their family and carers if appropriate, written and verbal information on what hemithyroidectomy or total thyroidectomy involves. Explain the benefits and risks of treatment, including long-term implications such as:
  • the effects of having part or all of your thyroid removed
  • the potential for and possible consequences of:
    • hypothyroidism and the subsequent need for lifelong thyroid hormone replacement
    • the need for treatment for low parathyroid hormone
    • voice change and swallowing disorders.

Information for People With Thyroid Cancer

• When giving people with thyroid cancer their diagnosis, even for low-risk thyroid cancers, it is important to acknowledge that this is a cancer diagnosis and allow the person time to ask questions and be fully informed
• Do not refer to thyroid cancer as a 'good cancer' because many people do not find this reassuring and it can cause them to feel that their diagnosis is unimportant
• Consider further appointments if they will benefit a person's psychological wellbeing, even if they are not indicated for physical reasons
• Give people with thyroid cancer, and their family and carers if appropriate, written and verbal information on:
  • who their key worker is and who to contact for more information
  • their thyroid cancer and its likely cure rate, effect on their life expectancy and likelihood of recurrence
  • the role and function of the thyroid gland and the need for long-term monitoring of thyroid function
  • how treatment may affect conception, pregnancy, breast feeding and fertility
  • the risks, benefits and uncertainties of treatment and its potential effects on their quality of life, energy, weight and mood
  • the roles of those involved in their treatment and follow up, and the composition of the multidisciplinary team
  • where to get reliable further information
• At follow up give people with thyroid cancer, and their family and carers if appropriate, information on:
  • follow up and how it is likely to be done
  • what thyroglobulin is, how it is measured and why
  • lifelong thyroid hormone replacement
  • lifelong monitoring of thyroid function
  • when to seek advice from a healthcare professional, who that healthcare professional should be and how to contact them.

Information for People Having Radioactive Iodine

• Offer people with suspected or confirmed thyroid cancer, and their family and carers if appropriate, written and verbal information on the benefits, and short- and long-term risks of radioactive iodine (RAI). Explain that:
  • the aim of RAI is to destroy any residual thyroid tissue, including tissue that may be malignant, and allows effective monitoring for recurrence by a blood test
  • precautions may be needed when taking RAI which may temporarily affect conception, pregnancy, breast feeding and fertility
  • although uncommon, there is the potential for dry mouth and salivary gland inflammation, both of which are temporary in most people
  • there is a potential but very low risk of RAI causing new primary second cancers.

Assessment and Diagnosis

Blood Tests

• See the recommendations on Investigating suspected thyroid dysfunction or thyroid enlargement in the NICE guideline on thyroid disease
• Do not use calcitonin testing to assess thyroid nodules unless there is a reason to suspect medullary thyroid cancer (MTC), such as a family history or a nodule with an appearance on ultrasound that suggests MTC
• Do not routinely measure thyroid peroxidase antibody (TPO)
• Consider TPO measurement when interpreting indeterminate cytopathology.

Ultrasound

• See the section on Investigating thyroid enlargement in the NICE guideline on thyroid disease
• Offer greyscale ultrasound with an established system for grading ultrasound appearance as the initial diagnostic test when investigating thyroid nodules for malignancy
• See the recommendations on grading and reporting ultrasound findings when investigating thyroid enlargement in the NICE guideline on thyroid disease.

Management Options Based on Ultrasound Results

• Offer fine needle aspiration cytology (FNAC) to people who meet the threshold using an established system for grading ultrasound appearance
• Consider FNAC or active surveillance for people who do not meet the threshold for FNAC on ultrasound grading alone if there are other reasons for clinical concern.

Fine Needle Aspiration Cytology Testing

Performing and Reporting Fine Needle Aspiration Cytology

• See the recommendation on using ultrasound guidance when performing FNAC in the NICE guideline on thyroid disease
• Use liquid-based cytology, direct smear or both when processing FNAC samples
• Use the Royal College of Pathologists modification of the British Thyroid Association (BTA) reporting system to report cytology results (Table 1)
• Consider rapid on-site evaluation of FNAC adequacy rates to improve the diagnostic yield of samples if the Thy1 (inadequate) rate for the centre or individual clinicians is higher than 15% (when Thy1c is excluded).

Table 1: Royal College of Pathologists Thyroid Cytology Categories

Management and Further Sampling After Initial FNAC

• Use the initial FNAC results to determine further management and sampling options, as shown in Table 2.

Table 2: Management Options After Initial Fine Needle Aspiration Cytology 

Radioisotope Scans

• Do not routinely use radioisotope scans for the initial diagnosis of thyroid cancer.

Imaging for Further Staging

• Do not routinely use cross-sectional imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) in people with T1 or T2 disease and no other indications
• Consider cross-sectional imaging (CT of neck and chest, or MRI of neck and CT of chest) for people with thyroid cancer that is T3 or T4, any N1 or M1 thyroid cancer or other clinical suspicion of metastases.

Initial Treatment of Differentiated Thyroid Cancer

Surgery and Active Surveillance for Primary Tumours

• When discussing surgical options with a person with differentiated thyroid cancer, take into account their preferences, comorbidities and all the available evidence regarding their tumour
• Offer hemithyroidectomy or total thyroidectomy to people with differentiated thyroid tumours larger than 1 cm or multifocal disease (T1a [m] to T2N0M0)
• Offer total thyroidectomy to people who have:
  • a T3 or T4 stage primary tumour
  • regional lymph node involvement (N1)
  • adverse pathological features
  • distant metastatic disease (M1)
• Offer completion thyroidectomy to people who have had a hemithyroidectomy if it is indicated on review of the histological features of the initial specimen
• Consider hemithyroidectomy or active surveillance for people with a solitary microcarcinoma (T1a) without evidence of nodal involvement.

Surgery for Nodal Disease

• Offer a compartment-orientated lateral neck dissection for people with structural nodal disease in the lateral neck
• Consider a prophylactic ipsilateral central neck dissection when doing the compartment-orientated lateral neck dissection for people with structural nodal disease in the lateral neck
• Offer a compartment-orientated central neck dissection for people with structural nodal disease in the central neck
• Do not offer prophylactic central or lateral neck dissection (except in the circumstances in the recommendation above).

Surgery During Pregnancy

• Consider deferring surgery until after pregnancy, taking into account:
  • the risk of delaying surgery
  • the risk to the pregnancy
  • the rate of disease progression

The obstetrician, surgeon and endocrinologist should discuss these factors and a joint decision should be reached in discussion with the pregnant woman.

• When surgery cannot be delayed until after pregnancy, it should be done during the second trimester if possible.

Thyrotropin Alfa

• Offer thyrotropin alfa for pretherapeutic stimulation for people with thyroid cancer (including those with distant metastases; see next recommendation) who are having RAI ablation.

In December 2022 this use of thyrotropin alfa as a treatment for thyroid cancer in people with distant metastases was off-label. See NICE's information on prescribing medicines.

• Use thyrotropin alfa with caution in people with thyroid cancer who have brain or spinal metastases, because there is a risk of clinically significant tumour flare.

RAI for Initial Ablation

• Offer RAI to people who have had a total or completion thyroidectomy based on the criteria in the recommendation on offering total thyroidectomy in the section on Surgery and active surveillance for primary tumours
• Do not offer RAI to people with T1a or T1b tumours including those with multifocal disease, unless there are adverse features, regional lymph node involvement, or evidence of other metastatic disease
• Consider RAI for people with T2 disease who have had a total or completion thyroidectomy, but whose disease does not show any of the features in the recommendation on offering total thyroidectomy in the section on Surgery and active surveillance for primary tumours.

RAI Activity for Initial Ablation

• Consider RAI with an activity for initial ablation of 3.7 GBq for people with high-risk features such as T4, N1b or M1 disease or aggressive subtypes, or people for whom multiple ablations should be avoided because they have one or more of the following characteristics:
  • significant comorbidities, such as cardiovascular disease
  • mobility issues
  • complex social concerns
• Offer RAI with an activity for initial ablation of 1.1 GBq to people who are not having 3.7 GBq.

External Beam Radiotherapy

• Consider external beam radiotherapy (EBRT) if there is macroscopic disease after surgery or local disease that is unlikely to be controlled with RAI
• Consider EBRT for symptom control for people receiving palliative care.

Ongoing Treatment With Thyroid Stimulating Hormone Suppression for Differentiated Thyroid Cancer

When to Offer Thyroid Stimulating Hormone Suppression

• Do not offer thyroid stimulating hormone (TSH) suppression to people who:
  • do not meet the threshold for RAI (see the section on RAI for initial ablation)
  • have significant comorbidities that mean low TSH levels should be avoided
• Offer thyroid hormone at doses that will suppress TSH to below 0.1 mIU/litre to people who have had total or completion thyroidectomy and RAI. TSH suppression should be continued until follow-up review at 9 to 12 months after initial treatment has been completed.

Assessing and Managing Response to TSH Suppression

• Use dynamic risk stratification to determine further management at 9 to 12 months after completion of initial RAI ablation, as follows:
  • Reduce TSH suppression to achieve a TSH level of between 0.3 mIU/litre and 2.0 mIU/litre and continue this for life in people with an excellent response to treatment
  • Continue TSH suppression to achieve a TSH level of between 0.1 mIU/litre and 0.5 mIU/litre in people who have an intermediate response to initial treatment
• Continue to suppress TSH to less than 0.1 mIU/litre in people who have biochemical or structural evidence of persistent or recurrent disease.

Long-term Duration of TSH Suppression

• Offer a review to people who have had ongoing TSH suppression for more than 10 years. Decide whether the TSH suppression can be reduced after an individualised assessment of risks and benefits, and explain that:
  • lifelong suppression is not necessary unless they have high-risk or metastatic disease
  • reducing TSH suppression may lower the risk of developing bone and cardiac problems.

Post-thyroidectomy Monitoring of Differentiated Thyroid Cancer

Measuring Thyroglobulin and Thyroglobulin Antibodies

• Be aware that:
  • the presence of thyroglobulin antibodies above the laboratory threshold can interfere with the measurement of thyroglobulin levels
  • detectable thyroglobulin levels in people without thyroglobulin antibodies suggest the presence of either residual thyroid tissue or residual or recurrent thyroid cancer
• Offer thyroglobulin measurement alongside measurement of thyroglobulin antibodies in people with differentiated thyroid cancer who have had total or completion thyroidectomy and RAI. Measure at:
  • 3- to 6-month intervals in the first 2 years after RAI ablation, and
  • 6- to 12-month intervals thereafter.
• Consider further investigations if a person has had total thyroidectomy and RAI, and:
  • has detectable thyroglobulin levels without thyroglobulin antibodies
  • investigations have not shown recurrent or residual cancer in the presence of detectable thyroglobulin without thyroglobulin antibodies, and now the thyroglobulin levels without thyroglobulin antibodies are rising
• Consider further investigations if a person has had a total thyroidectomy without RAI and has rising thyroglobulin levels without thyroglobulin antibodies
• Do not routinely measure thyroglobulin levels in people who have not had total or completion thyroidectomy
• Consider further investigation when thyroglobulin antibodies are first detected above the laboratory threshold or at any point if the levels of thyroglobulin or thyroglobulin antibodies are rising.

Stimulated Thyroglobulin and Highly Sensitive Thyroglobulin Testing

• Consider either a stimulated thyroglobulin test or highly sensitive thyroglobulin test if thyroglobulin is undetectable on a standard assay in people who have had a total or completion thyroidectomy and RAI, and have no evidence of structural persistent disease
• Consider the following if using a stimulated thyroglobulin test:
  • less frequent follow up, where appropriate, and more relaxed TSH suppression if stimulated thyroglobulin is below 1 microgram/litre (low risk)
  • continuing TSH suppression if stimulated thyroglobulin is between 1 microgram/litre and 10 microgram/litre (indeterminate risk)
  • further investigations and treatment if stimulated thyroglobulin is 10 microgram/litre or more and there is no resectable disease
• Consider the following if using a highly sensitive assay that can detect thyroglobulin levels lower than 0.2 microgram/litre:
  • less frequent follow up, where appropriate, and more relaxed TSH suppression if the thyroglobulin level is lower than 0.2 microgram/litre
  • stimulated thyroglobulin, which can be helpful in separating people into lower- and higher-risk groups if the thyroglobulin level is between 0.2 microgram/litre and 1 microgram/litre
• Use caution when interpreting results in the presence of thyroglobulin antibodies because they may cause false-positive or negative findings.

Follow Up of Differentiated Thyroid Cancer

• Do not routinely follow up people with thyroid cancer who have a solitary microcarcinoma (T1a) that has been surgically removed
• Consider an ultrasound at 6 to 12 months initially then annual clinical follow up for up to 5 years for people with T1a (m) or T1b stage or greater thyroid cancer, who have had a hemithyroidectomy or total thyroidectomy without RAI
• Consider a risk-stratified approach to follow up for any person who has had total or completion thyroidectomy and RAI (Twww.nice.org.uk/guidance/ng230able 3)
• Discuss at the multidisciplinary team meeting any person who has had a total or completion thyroidectomy and RAI and has evidence of structural persistent disease.

Table 3: Risk-stratified Follow Up for People Who Have Had a Total or Completion Thyroidectomy and Radioactive Iodine